In this episode, I’ll discuss new orders for fentanyl patches in the hospital setting.
Transdermal fentanyl patches are contraindicated in the treatment of acute pain or in patients who are not opioid tolerant.
This contraindication is in response to many reports of severe and fatal patient harm from the use of fentanyl patches for acute pain or in patients who are naive to opioids.
While oral opioids also have the potential to be harmful, if a patient becomes drowsy from too much opioid they will stop oral intake and this will allow for the opioid to wear off. Transdermal fentanyl has no such feedback opportunity and a patient prescribed too high of a dose will continue to absorb it, presenting the opportunity for opioid overdose.
The practice at my hospital has long been to verify all new orders for fentanyl patches before dispensing, ensuring that the patient is tolerant to opioids and that the indication is for longterm treatment of pain.
Authors from the Cleveland Clinic Euclid Hospital recently published in AJHP their own experiences optimizing the medication-use process for fentanyl patches at a small community hospital.
In 2017 the authors developed and implemented a procedure requiring an opioid status verification by a pharmacist for all fentanyl patch orders.
This 3-step procedure includes:
1. Determination of indication
2. Review of prior opioid use
3. Documentation within the medical record.
Throughout the implementation and analysis of this procedure, the hospital reduced their on-hand supply of fentanyl patches, made the patches less accessible, and identified additional safety and clinical education opportunities.
Success was measured by the number of fentanyl patch orders for acute pain. These numbers were:
11 or 45 orders (~24%) at baseline prior to implementation
1 of 13 orders (~8%) at year 1
2 of 24 orders (~8%) at year 2
While these numbers are small due to the single-center nature of the study, this is a set of common-sense and practical steps that can be taken to enhance fentanyl patch safety at any hospital if they are not already in place. Routinely following these steps when verifying new fentanyl patch orders is likely to prevent a potentially catastrophic event by stopping the use of fentanyl patches for acute pain and in opioid-naive patients.
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Does this apply to ICU patients being weaned off a fentanyl drip used during mechanical ventilation? Recently, some of the ICU physicians at my hospital have started using a TD patch to transition patients.
Those patients would technically not be using fentanyl patches for acute pain and would be tolerant of opioids, but I prefer to use other options for weaning off a fentanyl drip – see pharmacyjoe.com/episode72